Registered Nurse - Accreditation Manager

Summary

The Accreditation Manager is a professional nurse who functions as a coordinator and point of contact for external accreditation and other review activities for the Fayetteville North Carolina Coastal Health Care Center. The incumbent is a key person to help build and implement external accreditation/review systems and promote the culture of understanding the required standards and facilitate compliance in all healthcare settings.

Qualifications

Basic Requirements:

• English Language Proficiency
• In accordance with 38 U.S.C. 7403(f) - no person shall serve in direct patient care positions unless they are proficient in basic written and spoken English
• Graduate of a school of professional nursing approved by the appropriate accrediting agency and accredited by one of the following accrediting bodies at the time the program was completed by the applicant: The Accreditation Commission for Education in Nursing (ACEN) or The Commission on Collegiate Nursing Education (CCNE)
• OR Individuals attending a master's level bridge program in nursing who have completed coursework equivalent to a bachelor's level degree in Nursing may have opportunity to become registered as a nurse with a state licensing board prior to completion of the bridge program
• Upon achievement of a State license - the individual may be appointed on temporary basis and later converted to a permanent appointment upon successful completion and graduation from the bridge program
• (Reference VA Handbook 5005 - Appendix G6)
• OR In cases of graduates of foreign schools of professional nursing - possession of a current - full - active - and unrestricted registration will meet the requirement for graduation from an approved school of professional nursing to warrant an appointment as a Nurse who has completed an associated degree/entry level Nursing education program
• Credit for foreign nursing education higher that associate degree/entry level requires a formal degree equivalency validation from a recognized equivalency evaluation accepted by VA such as International Consultants of Delaware (ICD)
• Current - full - active - and unrestricted registration as a graduate professional nurse in a State - Territory or Commonwealth (i.e. - Puerto Rico) of the United States - or the District of Columbia
• Graduate Nurse Technician (GNT) Exception: Candidates who otherwise meet the basic education requirements - but do not possess the required licensure - may be appointed at the entry step of the grade and level applicable to the completed nursing education as a GNT on a 120-day temporary appointment while actively pursuing licensure (may be extended up to two years on a case-by-case-basis.) NOTE: Grandfathering Provision - All persons currently employed in VHA in 0610 series and performing the duties as described in the qualification standard on the effective date of the standard (1/29/2024) are considered to have met all qualification requirements for the grade held including positive education and licensure/certification
• Grade Determinations: The following Scope - Education and Dimension criteria must be met in determining the grade assignment of candidates - and if appropriate - the level within a grade
• The Dimension requirements (Practice - Veteran/Patient Driven Care - Leadership - Professional Development and Evidence-Based Practice/Research) are detailed for each grade and level within the online assessment:
• Grade/Level Scope Education Nurse I - Level I Delivers fundamental - knowledge-based care to assigned clients while developing technical competencies
• An Associate Degree (ADN) or Diploma in Nursing - with no additional professional nursing required
• Nurse I - Level II Demonstrates integration of biopsychosocial concepts - cognitive skills and technically competent practice in providing care to clients with basic or complex
• An ADN or Diploma in Nursing AND 1 year of specialized nursing experience equivalent to Nurse I - Level 1 ;OR a Bachelor of Science in Nursing (BSN) with no additional professional nursing experience required
• Nurse I - Level III Demonstrates proficiency in practice based on conscious and deliberate planning
• Self-directed in goal setting for managing complex client situations
• An ADN or Diploma in Nursing AND 2 years of professional nursing experience in which one year is equivalent to Nurse I - Level 2
• OR a BSN and 1 year of professional nursing experience equivalent to the Nurse I - Level 2
• OR a Master's degree in nursing (MSN) and no additional professional nursing experience
• OR a Master's degree in a *related field with a BSN and no additional professional nursing experience
• Nurse II Demonstrates leadership in delivering and improving holistic care through collaborative strategies with others
• A BSN with 2 years of professional nursing equivalent to Nurse I - Level 3
• OR an MSN with one year of specialized nursing experience equivalent to Nurse I - Level 3
• OR a Master's degree in a *related field with a BSN and one year of specialized nursing experience equivalent to Nurse I - Level 3
• OR a Doctoral degree in Nursing with no professional nursing experience
• OR a Doctoral degree in a *related field with a BSN with no additional professional nursing experience
• Nurse III Executes position responsibilities that demonstrate leadership - experience and creative approaches to management of complex client care beyond the immediate practice setting
• MSN and 2 years of specialized nursing experience - one of which is equivalent to Nurse II and meets all dimension requirements for Nurse III
• OR a Master's degree in *related field with BSN and two years of specialized nursing experience - one of which is equivalent to Nurse II and meets all dimension requirements for Nurse III
• OR a Doctoral degree in Nursing with and one year of specialized nursing experience equivalent to Nurse II and meets all dimension requirements for Nurse III
• OR a Doctoral degree in a *related field with a BSN and one year of specialized nursing experience equivalent to Nurse II and meets all dimension requirements for Nurse III
• *Note: Foreign education programs/degrees are not creditable as related degrees
• Preferred Experience: Experience with preparation - coordination - and knowledge of a variety of accreditation organizations and programs
• Experience with a wide range of specialized management analysis tools and techniques and applying these skills on difficult and complex work assignments
• Skill in preparing project papers and staff reports and in organizing and delivering briefings to managers to encourage understanding and acceptance of findings and recommendations
• Interpersonal skills in presenting recommendations and negotiating solutions to disputed recommendations
• Experience with pertinent laws - regulations - policies - and precedents which affect the use of administrative and related support resources in the area studied
• Experience in major issues - program goals and objectives - and work processes of the organization
• Ability to work well with others and across divisions Reference: For more information on this qualification standard - please visit
• Physical Requirements: This position requires visual acuity - keen hearing - clear distinctive speech - and manual dexterity
• The position requires potentially long periods of combined walking - standing - stooping - sitting - bending - pulling - and pushing
• The incumbent must be a mature - flexible - sensible individual capable or working effectively in stressful situation - able to shift priorities based on needs of the organization
• The incumbent who provides off-site training may be required to travel occasionally

Duties

• Duties include but are not limited to: The Accreditation Manager is assigned responsibility for the accreditation management program area activities for the Medical Center and all off-site locations
• The incumbent has primary responsibility for training and implementation of the standards applicable to each external accreditation/review (i.e. - TJC - CARF - OIG etc.) process to clinicians - management - and all relevant support personnel within facility
• The incumbent collects data - monitors staff compliance with relevant policies - directives - and standards - provides reports detailing trends - and provides direct staff support to all services in planning - designing - integrating - implementing - modifying - and administering - a comprehensive accreditation management program area
• Provides direct support to the development - maintenance - and operation of the external accreditation/review program at the facility level
• This includes working with all levels of staff within the facility - including executive-level management
• The incumbent also works with and assists external accreditation/review activities of similar personnel within the facility - such as the nursing and medicine clinical evaluators
• The incumbent is responsible for translating standards - policies - directives - theories - and strategies into action within the complex interrelationships that exist related to external accreditation/review
• .Executes the position responsibilities that demonstrate effective leadership - detailed planning - professional communication - creative and innovative approaches to the improvement of safety/healthcare program development and possess an ability to organize priorities
• The Accreditation Manager performs duties directly contributing to high quality and safe patient care within the Veterans Health Administration (VHA) VA offers a comprehensive total rewards package: VA Nurse Total Rewards Pay: Competitive salary - regular salary increases - potential for performance awards Paid Time Off: 50 days of paid time off per year (26 days of annual leave - 13 days of sick leave - 11 paid Federal holidays per year) Retirement: Traditional federal pension (5 years vesting) and federal 401K with up to 5% in contributions by VA Insurance: Federal health/vision/dental/term life/long-term care (many federal insurance programs can be carried into retirement) Licensure: 1 full and unrestricted license from any US State or territory Work Schedule: 8:00am - 4:30pm - Monday - Friday Telework: Ad-hoc Virtual: This is not a virtual position
• Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): Not Authorized

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The Veterans Health Administration (VHA) is the largest integrated health care system in the United States, providing care at 1,321 health care facilities, including 172 VA Medical Centers and 1,138 outpatient sites of care of varying complexity (VHA outpatient clinics) to over 9 million Veterans enrolled in the VA health care program. VHA Medical Centers provide a wide range of services including traditional hospital-based services such as surgery, critical care, mental health, orthopedics, pharmacy, radiology and physical therapy. In addition, most of our medical centers offer additional medical and surgical specialty services including audiology & speech pathology, dermatology, dental, geriatrics, neurology, oncology, podiatry, prosthetics, urology, and vision care. Some medical centers also offer advanced services such as organ transplants and plastic surgery.

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